Academic anaesthesiology: a global perspective on training, support, and future development of early career researchers.

As anaesthesiologists face increasing clinical demands and a limited and competitive funding environment for academic work, the sustainability of academic anaesthesiologists has never been more tenuous. Yet, the speciality needs academic anaesthesiologists in many roles, extending beyond routine clinical duties. Anaesthesiologist educators, researchers, and administrators are required not only to train future generations but also to lead innovation and expansion of anaesthesiology and related specialities, all to improve patient care. This group of early career researchers with geographically distinct training and practice backgrounds aim to highlight the diversity in clinical and academic training and career development pathways for anaesthesiologists globally. Although multiple routes to success exist, one common thread is the need for consistent support of strong mentors and sponsors. Moreover, to address inequitable opportunities, we emphasise the need for diversity and inclusivity through global collaboration and exchange that aims to improve access to research training and participation. We are optimistic that by focusing on these fundamental principles, we can help build a more resilient and sustainable future for academic anaesthesiologists around the world.

Noninvasive ventilation in COVID-19 patients aged ≥ 70 years-a prospective multicentre cohort study.

BACKGROUND: Noninvasive ventilation (NIV) is a promising alternative to invasive mechanical ventilation (IMV) with a particular importance amidst the shortage of intensive care unit (ICU) beds during the COVID-19 pandemic. We aimed to evaluate the use of NIV in Europe and factors associated with outcomes of patients treated with NIV. METHODS: This is a substudy of COVIP study-an international prospective observational study enrolling patients aged ≥ 70 years with confirmed COVID-19 treated in ICU. We enrolled patients in 156 ICUs across 15 European countries between March 2020 and April 2021.The primary endpoint was 30-day mortality. RESULTS: Cohort included 3074 patients, most of whom were male (2197/3074, 71.4%) at the mean age of 75.7 years (SD 4.6). NIV frequency was 25.7% and varied from 1.1 to 62.0% between participating countries. Primary NIV failure, defined as need for endotracheal intubation or death within 30 days since ICU admission, occurred in 470/629 (74.7%) of patients. Factors associated with increased NIV failure risk were higher Sequential Organ Failure Assessment (SOFA) score (OR 3.73, 95% CI 2.36-5.90) and Clinical Frailty Scale (CFS) on admission (OR 1.46, 95% CI 1.06-2.00). Patients initially treated with NIV (n = 630) lived for 1.36 fewer days (95% CI - 2.27 to - 0.46 days) compared to primary IMV group (n = 1876). CONCLUSIONS: Frequency of NIV use varies across European countries. Higher severity of illness and more severe frailty were associated with a risk of NIV failure among critically ill older adults with COVID-19. Primary IMV was associated with better outcomes than primary NIV. Clinical Trial Registration NCT04321265 , registered 19 March 2020, https://clinicaltrials.gov .

Association between tracheostomy timing and outcomes for older critically ill COVID-19 patients: prospective observational study in European intensive care units.

BACKGROUND: Tracheostomy is performed in patients expected to require prolonged mechanical ventilation, but to date optimal timing of tracheostomy has not been established. The evidence concerning tracheostomy in COVID-19 patients is particularly scarce. We aimed to describe the relationship between early tracheostomy (≤10 days since intubation) and outcomes for patients with COVID-19. METHODS: This was a prospective cohort study performed in 152 centres across 16 European countries from February to December 2020. We included patients aged ≥70 yr with confirmed COVID-19 infection admitted to an intensive care unit, requiring invasive mechanical ventilation. Multivariable analyses were performed to evaluate the association between early tracheostomy and clinical outcomes including 3-month mortality, intensive care length of stay, and duration of mechanical ventilation. RESULTS: The final analysis included 1740 patients with a mean age of 74 yr. Tracheostomy was performed in 461 (26.5%) patients. The tracheostomy rate varied across countries, from 8.3% to 52.9%. Early tracheostomy was performed in 135 (29.3%) patients. There was no difference in 3-month mortality between early and late tracheostomy in either our primary analysis (hazard ratio [HR]=0.96; 95% confidence interval [CI], 0.70-1.33) or a secondary landmark analysis (HR=0.78; 95% CI, 0.57-1.06). CONCLUSIONS: There is a wide variation across Europe in the timing of tracheostomy for critically ill patients with COVID-19. However, we found no evidence that early tracheostomy is associated with any effect on survival amongst older critically ill patients with COVID-19. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov NCT04321265.

Short-term mortality of patients ≥80 years old admitted to European intensive care units: an international observational study.

BACKGROUND: Limited evidence suggests variation in mortality of older critically ill adults across Europe. We aimed to investigate regional differences in mortality among very old ICU patients. METHODS: Multilevel analysis of two international prospective cohort studies. We included patients ≥80 yr old from 322 ICUs located in 16 European countries. The primary outcome was mortality within 30 days from admission to the ICU. Results are presented as n (%) with 95% confidence intervals and odds ratios (ORs). RESULTS: Of 8457 patients, 2944 (36.9% [35.9-38.0%]) died within 30 days. Crude mortality rates varied widely between participating countries (from 10.1% [6.4-15.6%] to 45.1% [41.1-49.2%] in the ICU and from 21.3% [16.3-28.9%] to 55.3% [51.1-59.5%] within 30 days). After adjustment for confounding variables, the variation in 30-day mortality between countries was substantially smaller than between ICUs (median OR 1.14 vs 1.58). Healthcare expenditure per capita (OR=0.84 per $1000 [0.75-0.94]) and social health insurance framework (OR=1.43 [1.01-2.01]) were associated with ICU mortality, but the direction and magnitude of these relationships was uncertain in 30-day follow-up. Volume of admissions was associated with lower mortality both in the ICU (OR=0.81 per 1000 annual ICU admissions [0.71-0.94]) and in 30-day follow-up (OR=0.86 [0.76-0.97]). CONCLUSION: The apparent variation in short-term mortality rates of older adults hospitalised in ICUs across Europe can be largely attributed to differences in the clinical profile of patients admitted. The volume-outcome relationship identified in this population requires further investigation.

Relationship between the Clinical Frailty Scale and short-term mortality in patients ≥ 80 years old acutely admitted to the ICU: a prospective cohort study.

BACKGROUND: The Clinical Frailty Scale (CFS) is frequently used to measure frailty in critically ill adults. There is wide variation in the approach to analysing the relationship between the CFS score and mortality after admission to the ICU. This study aimed to evaluate the influence of modelling approach on the association between the CFS score and short-term mortality and quantify the prognostic value of frailty in this context. METHODS: We analysed data from two multicentre prospective cohort studies which enrolled intensive care unit patients ≥ 80 years old in 26 countries. The primary outcome was mortality within 30-days from admission to the ICU. Logistic regression models for both ICU and 30-day mortality included the CFS score as either a categorical, continuous or dichotomous variable and were adjusted for patient's age, sex, reason for admission to the ICU, and admission Sequential Organ Failure Assessment score. RESULTS: The median age in the sample of 7487 consecutive patients was 84 years (IQR 81-87). The highest fraction of new prognostic information from frailty in the context of 30-day mortality was observed when the CFS score was treated as either a categorical variable using all original levels of frailty or a nonlinear continuous variable and was equal to 9% using these modelling approaches (p < 0.001). The relationship between the CFS score and mortality was nonlinear (p < 0.01). CONCLUSION: Knowledge about a patient's frailty status adds a substantial amount of new prognostic information at the moment of admission to the ICU. Arbitrary simplification of the CFS score into fewer groups than originally intended leads to a loss of information and should be avoided. Trial registration NCT03134807 (VIP1), NCT03370692 (VIP2).

Perioperative cardiovascular complications rate and activity of coagulation and fibrinolysis among patients undergoing vascular surgery for peripheral artery disease and abdominal aortic aneurysm.

OBJECTIVES: To compare preoperative coagulation and fibrinolysis activity and incidence of perioperative complications between patients undergoing vascular procedures for peripheral artery disease and abdominal aortic aneurysm. METHODS: This is a substudy of a prospective observational cohort study (VISION; NCT00512109) in which we recruited patients aged ≥45 years, undergoing surgery for peripheral artery disease and abdominal aortic aneurysm. Blood samples were obtained 24 h preoperatively to measure platelet count, concentrations of coagulation coagulation (fibrinogen, factor VIII, von Willebrand factor:Ristocetin cofactor, antithrombin III), fibrinolysis (dimer D, plasmin-antiplasmin complexes, tissue plasminogen activator) markers and level of soluble CD40 ligand. Incidence of myocardial infarction, stroke, and death (composite endpoint) was assessed in 30-day follow-up. RESULTS: The study group included 131 patients at the mean age of 68.3 years among whom reason for surgery was peripheral artery disease in 77 patients (58.8%) and abdominal aortic aneurysm in 54 patients (41.2%). Peripheral artery disease group was characterized by higher platelet count (250.5 versus 209.5 (×103/µl), p = 0.001), concentrations of fibrinogen (5.4 versus 4.1 (g/l), p < 0.001), factor VIII (176.9 versus 141.9 (%), p < 0.001), von Willebrand factor:Ristocetin cofactor (188.9 versus 152.3 (%), p = 0.009), and soluble CD40 ligand (9016.0 versus 7936.6 (pg/ml), p = 0.005). The dimer D level was higher (808.0 versus 2590.5 (ng/ml), p < 0.001) in the abdominal aortic aneurysm group. Incidence of major cardiovascular events (death, myocardial infarction, stroke) within 30 days from surgery did not differ between the groups (39.0% versus 29.6%, p = 0.27). CONCLUSIONS: The study suggests higher activation of coagulation and relatively lower fibrinolytic activity in peripheral artery disease group compared to patients undergoing surgery for abdominal aortic aneurysm without a significant difference in cardiovascular outcomes.

Myocardial injury after noncardiac surgery - an update.

PURPOSE OF REVIEW: After successfully reducing mortality in the operating room, the time has come for anesthesiologists to conquer postoperative complications. This review aims to raise awareness about myocardial injury after noncardiac surgery (MINS), its definition, diagnosis, clinical importance, and treatment. RECENT FINDINGS: MINS, defined as an elevated postoperative troponin judged to be due to myocardial ischemia (with or without ischemic features), occurs in up to one in five patients having noncardiac surgery and is responsible for 16% of all postoperative deaths within 30 days of surgery. New evidence on risk factors, etiology, potential prevention strategies, treatment options, and the economic impact of MINS highlights the actionability of perioperative clinicians in caring for adult patients who are considered to be at risk of cardiovascular complications. SUMMARY: Millions of patients safely going through surgery suffer MINS and die shortly after the procedure every year. Without a structured approach to predicting, preventing, diagnosing, and treating MINS, we lose the opportunity to provide our patients with the best chance of deriving benefit from noncardiac surgery. The perioperative community needs to come together, appreciate the clinical relevance of MINS, and step up with high-quality research in the future.

Preoperative levels of natriuretic peptides and the incidence of postoperative atrial fibrillation after noncardiac surgery: a prospective cohort study.

BACKGROUND: Postoperative atrial fibrillation (POAF) is associated with clinically significant short- and long-term complications after noncardiac surgery. Our aim was to describe the incidence of clinically important POAF after noncardiac surgery and establish the prognostic value of N-terminal pro-brain-type natriuretic peptide (NT-proBNP) in this context. METHODS: The Vascular events In noncardiac Surgery patIents cOhort evaluatioN (VISION) Study was a prospective cohort study involving patients aged 45 years and older who had inpatient noncardiac surgery that was performed between August 2007 and November 2013. We determined 30-day incidence of clinically important POAF (i.e., resulting in angina, congestive heart failure, symptomatic hypotension or requiring treatment) using logistic regression models to analyze the association between preoperative NT-proBNP and POAF. RESULTS: In 37 664 patients with no history of atrial fibrillation, we found that the incidence of POAF was 1.0% (95% confidence interval [CI] 0.9%-1.1%; 369 events); 3.2% (95% CI 2.3%-4.4%) in patients undergoing major thoracic surgery, 1.3% (95% CI 1.2%-1.5%) in patients undergoing major nonthoracic surgery and 0.2% (95% CI 0.1%-0.3%) in patients undergoing low-risk surgery. In a subgroup of 9789 patients with preoperative NT-proBNP measurements, the biomarker improved the prediction of POAF risk over conventional prognostic factors (likelihood ratio test p < 0.001; fraction of new information from NT-proBNP was 16%). Compared with a reference NT-proBNP measurement set at 100 ng/L, adjusted odds ratios for the occurrence of POAF were 1.31 (95% CI 1.15-1.49) at 200 ng/L, 2.07 (95% CI 1.27-3.36) at 1500 ng/L and 2.39 (95% CI 1.26-4.51) at 3000 ng/L. INTERPRETATION: We determined that the incidence of clinically important POAF after noncardiac surgery was 1.0%. We also found that preoperative NT-proBNP levels were associated with POAF independent of established prognostic factors. Trial registration: ClinicalTrials.gov, no. NCT00512109.

Myocardial Injury is More Common than Deep Venous Thrombosis after Vascular Surgery and is Associated with a High One Year Mortality Risk.

OBJECTIVE/BACKGROUND: Venous thromboembolism (VTE) has been considered the dominant major life threatening vascular complication after non-cardiac surgery, but recent studies have shifted the emphasis toward myocardial injury after non-cardiac surgery (MINS) as a common adverse event in the peri-operative setting. The aim of the present study was to compare the incidence and influence on mortality of two dominant venous and arterial events in the peri-operative period by prospectively screening a consecutive cohort of patients undergoing vascular surgery. METHODS: This was a sub-study of Vascular Events In Non-cardiac Surgery Patients Cohort Evaluation (VISION), the main objective of which was to evaluate major peri-operative complications after non-cardiac surgery. Patients undergoing vascular surgery had their blood collected to measure the Roche fifth generation high sensitivity troponin T (hsTnT) assay before and four times after surgery (6-12 h post-operatively, on the first, second, and third day following the procedure). MINS was defined as an elevated post-operative hsTnT ≥65 ng/L or an hsTnT ≥20 to <65 ng/L with an absolute change of ≥5 ng/L that was judged to be due to ischaemia. All patients underwent ultrasound venous compression testing for deep vein thrombosis (DVT) before, 4, and 7 days after surgery and follow-up was performed by telephone 30 days and 1 year after surgery. RESULTS: In total, 164 consecutive patients were included in this sub-study. MINS was diagnosed in 39 patients (23.8%) and DVT in four patients (2.4%). The 1 year mortality was higher in MINS (9/39 [23.1%]) than non-MINS patients (9/125 [7.2%]; p = .006). None of the patients who developed DVT died in the first year after surgery. CONCLUSION: MINS is a common complication after vascular surgery. It occurs more frequently than DVT and is associated with high 1 year mortality.

Prognosticating the outcome of intensive care in older patients-a narrative review.

Prognosis determines major decisions regarding treatment for critically ill patients. Statistical models have been developed to predict the probability of survival and other outcomes of intensive care. Although they were trained on the characteristics of large patient cohorts, they often do not represent very old patients (age ≥ 80 years) appropriately. Moreover, the heterogeneity within this particular group impairs the utility of statistical predictions for informing decision-making in very old individuals. In addition to these methodological problems, the diversity of cultural attitudes, available resources as well as variations of legal and professional norms limit the generalisability of prediction models, especially in patients with complex multi-morbidity and pre-existing functional impairments. Thus, current approaches to prognosticating outcomes in very old patients are imperfect and can generate substantial uncertainty about optimal trajectories of critical care in the individual. This article presents the state of the art and new approaches to predicting outcomes of intensive care for these patients. Special emphasis has been given to the integration of predictions into the decision-making for individual patients. This requires quantification of prognostic uncertainty and a careful alignment of decisions with the preferences of patients, who might prioritise functional outcomes over survival. Since the performance of outcome predictions for the individual patient may improve over time, time-limited trials in intensive care may be an appropriate way to increase the confidence in decisions about life-sustaining treatment.

The assessment of bladder cancer resectability with bimanual palpation: A prospective study in laparoscopy and open cystectomy patients.

PURPOSE: To evaluate the value of examination under anesthesia (EUA) in the assessment of bladder resectability during cystectomy. MATERIALS AND METHODS: This prospective study included consecutive patients undergoing cystectomy for bladder cancer at a single center between June 2017 and October 2020. EUA was conducted before cystectomy by two urologists who assessed the bladder for limited mobility. One examiner was blinded to the imaging results. Soft tissue surgical margin status in the pathological evaluation of a cystectomy specimen served as a measure of resectability. We used multivariable logistic regression models to assess whether EUA performed by blinded or non-blinded examiners is associated with soft tissue positive surgical margins (PSMs) and to calculate the fraction of new information added by such an examination in addition to selected clinical variables. RESULTS: Among the 134 patients analyzed, limited bladder mobility was indicated by the blinded and non-blinded examiners in 23 (17.2%) and 21 (15.7%) cases, respectively. PSMs were identified in 22 (16.4%) patients, more often in patients with limited bladder mobility as assessed by the blinded (odds ratio [OR] 6.7; 95% confidence interval [CI], 1.9-24.2) and non-blinded examiners (OR 12.9; 95% CI, 2.9-57.5). The fraction of new information added by the blinded and non-blinded examiners was 48.6% and 57.7%, respectively. The enrichment of patients who underwent pure laparoscopic cystectomy (n = 102; 76%) and the inclusion of patients for emergent surgery may limit the generalizability of our findings. CONCLUSIONS: The identification of limited bladder mobility during preoperative EUA yielded prognostic information on surgical margin status. Our findings suggest that EUA has the potential to provide valuable insights in the assessment of bladder resectability. However, further research in a larger cohort of patients is warranted to validate and expand on these findings.

Association between self-reported functional capacity measures and postoperative myocardial injury in patients undergoing noncardiac surgeries.

BACKGROUND: Self-reported functional capacity measures have an uncertain role in the pre-operative cardiovascular risk stratification. AIM: This substudy aimed to evaluate whether self-reported metabolic equivalent (MET) could improve the prediction of postoperative myocardial injury (MI) over other well-established cardiovascular risk factors. METHODS: This is a post hoc analysis of an international multicenter prospective cohort study. We recruited patients ≥45 years old who had elective elevated-risk noncardiac surgery in 45 centers across 17 countries between June 2017 and April 2020. The primary outcome was MI defined according to the Fourth Universal Definition of Myocardial Infarction. We measured the proportion of new prognostic information added by self-reported MET using multivariable logistic regression. RESULTS: In total, 860 (41.3%) patients suffered MI. In patients without systematic troponin surveillance, the odds ratio for MI with each 1-point increment in MET equaled 1.03 (95% confidence interval [CI], 0.99-1.07). The new prognostic information, according to the likelihood ratio adequacy index, accounted for 1.5%. Sensitivity analysis, including centers with >90% of patients with routine high-sensitivity troponin T monitoring, showed that MET added 21.8% of new information to the baseline model, and each additional point was associated with a lower risk of MI (odds ratio, 0.86; 95% CI, 0.81-0.91). CONCLUSIONS: In elevated-risk noncardiac surgery, self-reported functional capacity measures do not significantly improve the prediction of MI; however, they add new prognostic information in centers with routine perioperative troponin monitoring.

Prevalence of life-sustaining treatment limitations in Polish very old intensive care patients (VIPs). A post-hoc analysis of two prospective observational studies.

PURPOSE: Several initiatives have recently focused on raising awareness about limitations of treatment in Poland. We aimed to assess if the propensity to limit LST among elderly patients in 2018-2019 increased compared to 2016-2017. METHODS: We analysed Polish cohorts from studies VIP1 (October 2016 - May 2017) and VIP2 (May 2018 - May 2019) that enrolled critical patients aged >80. We collected data on demographics, clinical features limitations of LST. Primary analysis assessed factors associated with prevalence of limitations of LST, A secondary analysis explored differences between patients with and without limitations of LST. RESULTS: 601 patients were enrolled. Prevalence of LST limitations was 16.1% in 2016-2017 and 20.5% in 2018-2019. No difference was found in univariate analysis (p = 0.22), multivariable model showed higher propensity towards limiting LST in the 2018-2019 cohort compared to 2016-2017 cohort (OR 1.07;95%CI, 1.01-1.14). There was higher mortality and a longer length of stay of patients with limitations of LST compared to the patients without limitations of LST. (11 vs. 6 days, p = 0.001). CONCLUSIONS: The clinicians in Poland have become more proactive in limiting LST in critically ill patients ≥80 years old over the studied period, however the prevalence of limitations of LST in Poland remains low.

Predictors of outcomes of patients ≥ 80 years old admitted to intensive care units in Poland - a post-hoc analysis of the VIP2 prospective observational study.

INTRODUCTION: Elderly patients pose a significant challenge to intensive care unit (ICU) clinicians. In this study we attempted to characterise the population of patients over 80 years old admitted to ICUs in Poland and identify associations between clinical features and short-term outcomes. MATERIAL AND METHODS: The study is a post-hoc analysis of the Polish cohort of the VIP2 European prospective observational study enrolling patients > 80 years old admitted to ICUs over a 6-month period. Data including clinical features, clinical frailty scale (CFS), geriatric scales, interventions within the ICU, and outcomes (30-day and ICU mortality and length of stay) were gathered. Univariate analyses comparing frail (CFS > 4) to non-frail patients and survivors to non-survivors were performed. Multivariable models with CFS, activities of daily living score (ADL), and the cognitive decline questionnaire IQCODE as predictors and ICU or 30-day mortality as outcomes were formed. RESULTS: A total of 371 patients from 27 ICUs were enrolled. Frail patients had significantly higher ICU (58% vs. 44.45%, P = 0.03) and 30-day (65.61% vs. 54.14%, P = 0.01) mortality compared to non-frail counterparts. The survivors had significantly lower SOFA score, CFS, ADL, and IQCODE than non-survivors. In multivariable analysis CFS (OR 1.15, 95% CI: 1.00-1.34) and SOFA score (OR 1.29, 95% CI: 1.19-1.41) were identified as significant predictors for ICU mortality; however, CFS was not a predictor for 30-day mortality ( P = 0.07). No statistical significance was found for ADL, IQCODE, polypharmacy, or comorbidities. CONCLUSIONS: We found a positive correlation between CFS and ICU mortality, which might point to the value of assessing the score for every patient admitted to the ICU. The older Polish ICU patients were characterised by higher mortality compared to the other European countries.

Validity of the total SOFA score in patients ≥ 80 years old acutely admitted to intensive care units: a post-hoc analysis of the VIP2 prospective, international cohort study.

BACKGROUND: Little is known about the performance of the Sequential Organ Failure Assessment (SOFA) score in older critically ill adults. We aimed to evaluate the prognostic impact of physiological disturbances in the six organ systems included in the SOFA score. METHODS: We analysed previously collected data from a prospective cohort study conducted between 2018 and 2019 in 22 countries. Consecutive patients ≥ 80 years old acutely admitted to intensive care units (ICUs) were eligible for inclusion. Patients were followed up for 30 days after admission to the ICU. We used logistic regression to study the association between increasing severity of organ dysfunction and mortality. RESULTS: The median SOFA score among 3882 analysed patients was equal to 6 (IQR: 4-9). Mortality was equal to 26.1% (95% CI 24.7-27.5%) in the ICU and 38.7% (95% CI 37.1-40.2%) at day 30. Organ failure defined as a SOFA score ≥ 3 was associated with variable adjusted odds ratios (aORs) for ICU mortality dependant on the organ system affected: respiratory, 1.53 (95% CI 1.29-1.81); cardiovascular 1.69 (95% CI 1.43-2.01); hepatic, 1.74 (95% CI 0.97-3.15); renal, 1.87 (95% CI 1.48-2.35); central nervous system, 2.79 (95% CI 2.34-3.33); coagulation, 2.72 (95% CI 1.66-4.48). Modelling consecutive levels of organ dysfunction resulted in aORs equal to 0.57 (95% CI 0.33-1.00) when patients scored 2 points in the cardiovascular system and 1.01 (0.79-1.30) when the cardiovascular SOFA equalled 3. CONCLUSIONS: Different components of the SOFA score have different prognostic implications for older critically ill adults. The cardiovascular component of the SOFA score requires revision.